COMPLETE THIS APPLICATION AND RETURN TO: Office of Health Facility Attention: Assisted Living Program 408 Leon Sullivan Way Charleston, WV 25301-1713 (304) 558-0050 LOG NUMBER DATE OFFICIAL USE ONLY NOTE: This application can only be accepted if all required fields are completed and additional requested documentation is attached. FACILITY INFORMATION Legal FEIN: Physical Mailing County Phone: ( ) Fax: ( ) E-mail Website URL: OCCUPANCY Number of private rooms: Private room daily rate: $ Number of semi-private rooms: Semi-private room daily rate: $ Number of 3 4 bed wards: 3 4 bed ward daily rate: $ Does the facility accept residents with Supplemental Security Income (SSI)? Yes No If yes, what is the daily rate: $ Total number of beds in facility: Total number of beds allocated to low income residents: Total number of beds allocated for day care: 1 P a g e
SERVICES Check the provider(s) for all services offered: Facility Contract Facility Contract 24-hour Security Activities Administrative Office Alzheimer Care Appointment Transportation Cable Television Day Care Services Field Trips Hospice Laboratory Management of Personal Finances Mobile X-Ray Occupational Therapy Pharmacy Services Physician Services Speech Therapy 24-hour Supervised Care Activities of Daily Living All Utilities Included Appointment Scheduling Beauty Shop Church Services Dietary Services Home Health Services Housekeeping Services Library Medication Administration Nursing Services Pet Therapy Physical Therapy Podiatry Other ADMINISTRATOR Full Last First M.I. E-mail WV Administrator s License Number: Expiration Date: SUPERVISING/CONSULTANT REGISTERED NURSE Full E-mail Last First M.I. License Number: Expiration Date: 2 P a g e
STAFFING Provide the number of full-time personnel for each of the positions listed below: General Physician Services Administration Dentists Housekeeping Pharmacists Podiatrists Other Therapeutic Services Occupational Therapists Occupational Therapy Aides Physical Therapists Physical Therapy Aides Speech/Language Pathologists Activities Staff Physician Physician Assistant Nursing Services RN Director of Nurses Nurses w/ Administrative Duties Registered Nurses Licensed Practical Nurses Personal Care Aides Residential Aides Approved Medication Assistive Personnel Dietary Services Dietitian Food Service Workers OWNER INFORMATION Legal Type of Ownership (Check only one): Proprietary: Individual Partnership Corporation Limited Liability Company Non-profit: Church-Related Non-profit Corporation Other Government: State County City City/County Other Mailing Phone: ( ) Fax: ( ) E-mail Website URL: 3 P a g e
SHAREHOLDERS Director Officer Stockholder Trustee/Beneficiary Principle Occupation: Proprietary Interest: % SHAREHOLDERS Director Officer Stockholder Trustee/Beneficiary Principle Occupation: Proprietary Interest: % OTHER FACILITIES OWNED OR OPERATED BY APPLICANT OTHER FACILITIES OWNED OR OPERATED BY APPLICANT 4 P a g e
APPLICANT Title or Position: Relationship to Facility: Lessee or assignee of the facility Owner Signature: Date: VERIFICATION STATE OF WEST VIRGINIA County of, being by me duly sworn on his/her oath, deposes and says that he/she has read the foregoing application and knows the contents thereof: that the statements concerning the above named Center/Agency, therein contained, are correct and true of his/her own knowledge. Signature of Applicant: Subscribed and sworn to before me this day of, 20. Notary Public My Commission Expires: 5 P a g e